Tag: child abuse

The overlap between traumatic brain injury (TBI) and violence is an important yet little understood problem. The exact number of violence-related TBIs each year is not known. The Centers for Disease Control and Prevention (CDC) estimates that 11% of TBI deaths, hospitalizations, and ED visits combined (a total of 156,000 each year) are related to assaults (Langlois et al, 2004). But this number likely is low because it excludes the many other TBIs, including concussions, caused by violence that go unidentified and unreported. Although not a focus of this article, prisoners and young children are two of the groups at high risk of a violence-related TBI that may not be identified. (See articles by Wald, et al, and Berger, this issue).

Furthermore, the problem of TBI and violence is complicated by the fact that violence is not only a cause, but a consequence of TBI. Specifically,TBI-related cognitive and behavioral problems can also result in aggressive behavior that leads to perpetration of violence, or a lack of insight and judgment, and resulting vulnerability, that can lead to victimization. Depression after TBI can lead to an increased risk of self-inflicted injury, including suicide (Oquendo et al., 2004). Although not a focus of this article, suicide is an important aspect of violence that is addressed elsewhere in this issue (See Brenner article).

The goal of this article is to increase awareness among TBI and health care professionals about the overlap between TBI and violence by summarizing the epidemiology and providing case examples for victimization and aggressive behavior. In addition, we focused on intimate partner violence and TBI because of the limited information published about this topic.

Violence as a Cause of Traumatic Brain Injury

Intimate Partner Violence

The term intimate partner violence (IPV) is also known as domestic violence, spouse abuse, or woman abuse. An “intimate partner” is defined as a current or former partner, including a spouse, boyfriend, or girlfriend (Saltzman et al., 1999). After a relationship ends, many people continue to be at risk for violence from former partners. Intimate partners can be the opposite or the same sex as the victim (Burke et al., 1999; Moracco et al., 2007).

Each year in the United States, women experience about 4.8 million intimate partner-related physical assaults and rapes; men are the victims of about 2.9 million intimate partner violencerelated physical assaults (Tjaden et al., 2000). However, these numbers may underestimate the extent of the problem as certain populations who are more likely to report IPV (prisoners, those living in shelters, transient people, and the homeless) are less likely to be surveyed.

The number of cases of TBI associated with intimate partner violence is not known. However, as mentioned above, CDC estimates that at least 156,000 TBI-related deaths, hospitalizations, and emergency department visits in the U.S. each year are related to assaults (Langlois, et al., 2004). Strangulation or blows to the head may occur in 50 to 90 percent of IPV physical assaults against women (Wolfe et al, 1997; Greenfield et al., 1998). Thus, the true number of violence-related TBIs may be much higher than the CDC estimate. Multiple TBIs, including concussions are frequently reported by incarcerated women with a history of IPV (Pamela Diamond, PhD, University of Texas-Houston, Personal Communication, October 2007).

In one study, 60 percent of the women with IPV-related TBI continued to exhibit TBI-related symptoms 3 months after the injury (Monahan and O’Leary, 1999). Women with TBI frequently exhibit reduced capacity to make informed, consistent choices about whether to leave or return to the perpetrating partner, and their ability to plan and to respond appropriately to safety, health, child care, and parenting issues may be significantly compromised (Monahan and O’Leary, 1999). This increases the likelihood that they will remain in a violent relationship and the risk of sustaining additional injuries, including TBI.

Many victims do not report IPV to police, friends, or family because they think others will not believe them and that the police cannot help (Tjaden et al., 2000).

This may be particularly true for persons with traumatic brain injury (Reichard et al., 2007) for several reasons. First, individuals with TBI are more likely to be dependent on a perpetrator for financial support and physical care. Second, communication problems associated with TBI may make it difficult for victims to report victimization. Third, the perpetrator may claim that the victim should not be taken seriously because of their TBI-related cognitive problems. Finally, victims may not be willing to admit that they have had a TBI because of the fear of negative consequences such as losing custody oftheir children.

Case example

Debra was born in in 1952. She spent 10 years in an abusive relationship with her female partner, and during that time sustained several possible concussions. In 2000, she was lying in bed asleep and was shot several times, including once in the head. She was rushed to the ER and remained in the hospital for 9 days for cranial hemorrhaging. (See sidebar “One Woman’s Story” for a more detailed account)

(Published with permission from Ms. Gray, obtained by the
Alabama Department of Rehabilitation Services)

Violence as a Consequence of TBI

Victimization

A victim is defined as a target of emotional abuse or threatened or actual physical or sexual violence (Saltzman, et al., 2002). Victimization can include physical violence, sexual violence, psychological or emotional abuse, stalking, and neglect.

Persons with disabilities are particularly vulnerable to violence, and their position of vulnerability often makes it more difficult to leave a violent situation. The number of persons with TBI in the U.S. who are victimized each year is not known and existing information regarding the victimization of persons with disabilities has been gleaned from a small number of studies (Marge, 2003). Such studies have shown that persons with disabilities are 4 to 10 times more likely to become a victim of violence, abuse, or neglect than persons without disabilities (Petersilia, 2001). One recent study found that men and women with activity limitations were more likely to experience physical, emotional, and financial abuse, and that women with activity limitations were more likely to experience sexual abuse (Cohen, et al., 2006). Another study found that women with disabilities were 40% more likely to experience intimate partner violence than women without disabilities (Brownridge, 2006).

Research suggests that certain conditions increase the likelihood of violence, abuse or neglect. One study found that violence was more likely among women with a physical disability when they also had more than one disability, a hearing impairment, or were divorced/separated (Milberger, et al., 2003). Another study found that men and women with activity limitations were more likely to report intimate partner violence if they were single, younger, had lower income, and/or had poor health (Cohen, et al., 2006). (For more detailed information about victimization, see the sidebar).

Little is known about the experience of victimization among persons with TBI, however. A recent qualitative research report by Reichard et al. (2007) has begun to shed some light on the problem and provides a number of examples. Selected narratives collected as part of this study are presented below.

Case examples

Victimization of persons with TBIPhysical abuse

I guess because I had on a shirt he didn’t like. I remember it was something about clothes and he threatened to cut the shirt off my body, and I told him he wasn’t cutting the shirt off my body, that I’d go take it off, and then he was going to cut the shirt to shreds, and I told him no, he wasn’t. That I’d take the shirt off but he wasn’t cutting the shirt up, and something about the shirt. He didn’t like the shirt or something, and he had the scissors and he got mad, and I took the scissors away from him, and that’s the only way I’d take off the shirt if he gave me the scissors, and that’s when he pounded me in the head.

Physical and financial abuse

Saturday evening, this fellow [name], who I was going to marry, he tore…he gave me a black eye, he tore up my apartment and demanded a $300 check. [This was not the first time this happened]. He’d hit me and stuff like that. I’ve gone to work with a black eye.

Seeking protection

I went to the police to see what I could do. They told me the temporary restraining order wasn’t worth the paper it was written on. They told me basically it was all a joke. I could get it, but he could show up with a gun and blow me away. That if I was going to do anything, I needed to do it and disappear. I needed to go out of state. I needed to file the papers, go out of state, and then not show up until the day of the court date. That I needed to go ahead and get what I needed done, do it fast, and then leave the state of [state name]. I told them I didn’t have no money. I didn’t have…if I left the state of [state name], how was I going to live? Where was I going to live? How was I going to get there? Due to seizures, I couldn’t drive. I didn’t have no way of driving. What was the deal? And they said they couldn’t help me.

Sexual abuse

I was at a car dealership … getting the car serviced and everything. This elderly man walked in, big smile on, plopped down right next to me, started talking to me very friendly. I started feeling very comfortable with him. Felt like he was like a father figure, you know because my father died when I was…about 5 or 6 years old. Then he started. He put his arm out back behind me. It was a loveseat type thing, which I was feeling very comfortable with him because I was identifying with a father. He started asking questions and so I was talking with him about [the problems he said he was having with his wife and what he could do about them]. And with that he kept getting closer to me… and he moved his hand from the back of the sofa down to the seat and all of a sudden I became aware he was shoving his hand at my butt, up under it and had his thumb stroking my thigh on the outside… my hip area…he was still engaging me in the conversation so that was distracting me…The next thing I know he’s got his hand up my short leg, over into my pubic area, probing, massaging, and I’m looking at him. What are you doing? He said…oh, you’ve just given me the thrill of my life today. And I said remove your hand… I came home rattled…The first thing I did was pick up the phone and I called [name of state] and talked to my friend there and I told him what happened, and I was in hysterics. I mean I was sobbing. I was frantic. I was shaking as I was holding the phone. It’s like I don’t understand why do these things keep happening, you know, and we talked about it and that’s when I first got the insight. He talked to me. He was friendly. You know, he was gentle. He started off appropriate. He kept me distracted, and he was the perfect predator…I’ve been in a situation of no control, … and … distracted, not really able to anticipate where stuff is going. I’m just trying to deal with each moment, so I mean that’s a problem because that means I’m wide open for rape and anything else, and I’ve been fortunate so far no one’s raped me. They’ve molested me, but they have not raped me.

Sexual abuse by a medical professional

It was the second [gynecological exam] in my whole life… [The doctor] dismissed the nurse and he told me to change into a paper gown and he didn’t leave the room….Yeah. And he made me put the thing so it opened in the front…, and then he came over and he pulled the paper open at my breast and everything and he was just looking and his looks were bedroom looks…., and then he took his hands and he started fondling my breasts. After [talking to me about sex and masturbation and touching my private area in a sexual way] … he put [the speculum] in hot and he said I can sterilize you if you ever tell anybody and besides you’ve got a brain injury. They’re not going to believe you.

Violence as a consequence of TBI

Aggressive behavior

According to Silver et al (2005), aggressive behavior after TBI includes explosive behavior that can be set off by minimal provocation and occur without warning. Episodes range in severity from irritability to outbursts that result in damage to property or assaults on others.

Reports of the incidence of aggression vary widely. Studies of patients with TBI conducted in medical outpatient settings typically report low rates of aggressive behavior (Kreutzer et al, 1999). In contrast, persons in a TBI neurobehavioral program displayed an average of about 280 aggressive acts per day during a 14-day period (Alderman et al, 2002). Sexual aggression was reported in 6.5% of a sample of male patients receiving either inpatient or outpatient TBI rehabilitation; the most common offenses were “touching” offenses followed by exhibitionism and overt sexual aggression (Simpson et al., 1999) Increasing evidence suggests that TBI-related aggressive behavior is strongly associated with depression (Kreutzer et al,1996; Tateno et al, 2003; Baguley et al, 2006).

Case examples

Paul was a new 16 year-old driver when he ran his car off the road and both he and his girlfriend sustained TBIs. After a 2 month coma and years of recovery, his social skills have not caught up with his age of 24. He was taken by police to the emergency room when a group of guys beat him severely and took his wallet. Surprised and humiliated, he responded, ”I don’t understand. I just asked them ‘do you want some of this.’ I guess they thought I wanted to fight because they just started beating me up.” Now four years later, despite his best intentions, he loses new friends when he throws things and screams obscenities at them. “They are looking at me and talking too loud” he says. “I said I’m sorry, I go too far before I know it.”

After sustaining a brain injury in Iraq, Steve was diagnosed with post-traumatic stress disorder and depression. One of the effects of his brain injury is that he has a harder time keeping his emotions under control. He blurts out what he’s thinking or flashes his anger. Late one night driving his pickup truck, he and his wife, came to an intersection where he usually turned left. Now there was a ‘No left turn’ sign. Confused, he stopped and tried to figure out what to do. A policeman walked up. According to his wife “The cop, he shines the flashlight right in at Steve, and he’s screaming, ‘Can you not read, stupid?’ and he got irate. Steve said to his wife, ‘This guy just called me stupid.’ He let out the clutch on the truck and yelled at the cop. ‘I’ll show you stupid, because I’m not stupid. It just takes me longer to comprehend.’ ” He wanted to get out of the car then, but his wife told him “No, it’s not worth it.” She calmed him down and the couple drove on. In rehab, Steve is learning strategies to jog his memory and control his anger. He says “I bite my tongue so many times. I–they’ve taught me to really walk off, and it’s a hard thing for me to do, but I’m learning that.”

Reducing the toll of violence after TBI

Victimization

Screening for possible TBI among persons who have experienced intimate partner violence is critical to ensuring that those with TBI-related problems are diagnosed and receive needed services and/or accommodations. Professionals working in IPV prevention can benefit from information and training aimed at helping them identify and manage persons with TBI. Potentially useful methods for screening, identifying and assisting such cases have been proposed by both the Alabama Department of Rehabilitation Services and the Brain Injury Association of Virginia (See Interview with Maria Crowley, this issue, and sidebar of Intimate Partner [Domestic] Violence Resources). Additional research is needed to ensure that the screening methods for identifying TBI are both valid and reliable. The November-December 2007 issue of the Journal of Head Trauma Rehabilitation, which was devoted to articles about screening and identification of TBI, includes information about promising new screening methods.

Similarly, screening for victimization among persons with TBI is also important. Physicians are especially well-placed to conduct such screening. However, recent studies of the screening practices of physicians, including obstetrician–gynecologists, indicate that most conduct screening for violence only when warning signs are observed (Horan et al., 1998; Rodriguez et al., 1999).

Unfortunately, violence can exist in the absence of warning signs in the patient’s behavior or medical history. Women who are victims of violence may not present with symptoms, especially those who experience psychological or emotional abuse. They may conceal what they are experiencing at home. Because of the increased vulnerability of women with disabilities, including those with TBI, it is important to study the utility of screening these patients for IPV.

One of the most widely used screening tools is the Abuse Assessment Screen (McFarlane et al, 1992). This tool is short and has been tested in clinical settings. This and other tools for assessing IPV can be found in the Centers for Disease Control’s publicationIntimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings. [See Intimate Partner (Domestic) Violence Resources sidebar, page 16.]

Aggressive behavior

The need to improve the effectiveness of strategies to manage the anger, aggression, and disinhibition following TBI has been well established (Corrigan and Bach, 2005). The link between TBIrelated behavioral problems and violent victimization described in this article provides an additional reason why work in this area is vitally important. Improvements in behavioral management techniques might yield benefits beyond achieving reductions in problematic behaviors. This could include reduced risks for the forms of victimization that may accompany diminished coping abilities, impulse control problems, and increased irritability.

Conclusion

Violence as both a cause and a consequence of TBI is a serious problem. TBI professionals can play an important role in educating domestic violence workers, health care providers, and other professionals, including those in law enforcement, about ways to better identify and assist persons who experience violence. Additional research is needed to better quantify the extent of the problem and to ensure that screening methods for identifying a history of TBI are valid and reliable.

About the Authors

Jean A. Langlois, ScD, MPH is a senior epidemiologist with the Centers for Disease Control and Prevention. She holds master’s and doctoral degrees in injury epidemiology and health policy from the Johns Hopkins University School of Hygiene and Public Health. Dr. Langlois worked in pediatric traumatic brain injury rehabilitation at the Kennedy Krieger Institute at Johns Hopkins Hospital, and was a Senior Staff Fellow in epidemiology at the National Institute on Aging of the National Institutes of Health before joining the CDC. She has published numerousarticles and reports on traumatic brain injury, and is considered a national expert on the epidemiology of TBI. In 2006, she was the recipient of the Brain Injury Association of Ohio’s Awareness Award, and the North American Brain Injury Society’s Public Policy Award

Jeffrey E. Hall, Ph.D., M.S.P.H. is a behavioral scientist with CDC’s Division of Violence Prevention. He is a medical sociologist whose research has focused on etiologic aspects of youth violence, elder maltreatment, and violence against women.

Matt Breiding, Ph.D. is a behavioral scientist with CDC’s Division of Violence Prevention. He is a psychologist whose research has focused on the topics of intimate partner violence and sexual violence.

Audrey A. Reichard MPH, OTR is an epidemiologist who currently conducts research on occupational injuries at the CDC, National Institute for Occupational Safety and Health, Division of Safety Research. She previously worked in the CDC, National Center for Injury Prevention and Control, Division of Injury Response. Prior to beginning a full-time research position, she practiced as an occupational therapist.

Ms. McDonnell is the Executive Director of the Brain Injury Association of Virginia. She has a Bachelor of Science in Occupational Therapy from the Medical College of Virginia, a postgraduate Certificate in Health Care Management and Administration from Old Dominion University, and a Masters of Public Administration degree from Virginia Commonwealth University (VCU). Anne has over 20 years of experience in brain injury rehabilitation across a continuum of hospital and community based settings, and has worked as a consultant for state agencies and private service providers. She serves on the advisory boards for the VCU and Ohio Valley Center Traumatic Brain Injury Model Systems grants, and holds a clinical faculty position in the School of Occupational Therapy at VCU.

Marlena Wald, MLS, MPH is an epidemiologist at the National Center for Injury Prevention and Control, CDC. She has a strong interest in research on victimization of persons with TBI and is the developer CDC’s fact sheets on this topic and on TBI among prisoners.

Langlois, J.A., Rutland-Brown, W., and Thomas, K.E. (2004) Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Marge K. Introduction to violence and disability. In: Marge K, editor. A call to action: Ending crimes of violence against children and adults with disabilities, a report to the nation. Syracuse: State University of New York, Upstate Medical University; 2003. p. 1-16.

The “One Punch Kills” campaign in Australia has been successful in some respect to address violence amongst men on men. What has not been addressed is just one aggressive act of violence can leave a brain injury resulting from domestic violence.

They say one in three women in Australia are hospitalised each week and diagnosed with a Traumatic Brain Injury due to Domestic Violence. Yet the numbers are actually higher. I have met plenty of women and children who are diagnosed with a brain injury after leaving a violent relationship. They are not part of these statistics.

There is no real detailed research into Traumatic Brain Injury resulting from domestic violence. My own Traumatic Brain Injury was a result of Family Violence. I hid the diagnosis for five years because the stigma of such an injury.

Why? Well from other survivors of Domestic Violence, I learnt early on from their experiences that even discussing a brain injury resulting from domestic violence was frowned upon, and literally taboo.

Here as some of the survivors stories:

Human Services suggests that such an injury could have an effect on being “capable mother” children were put into state care for three years. (2012)

Victoria Police told one survivor that maybe “she asked for it” and that a man only gets that angry “when provoked”. The assault was investigated, (no medical records accessed) and no charges laid. (2014) She was unable to get Victims of Crime Compensation, because in Victoria if the person is not charged with an offence, you are cross examined by them at the Tribunal. She refused to be retraumatised by his abuse.

Centrelink informed one mother that even though she had a Brain Injury (and that qualified her fro a disability pension) the injury was a result from her own behaviour. It took 18 months, three reviews at Centrelink, and then VCAT to be given a disability pension. (2015). Apparently if you acquire a traumatic brain injury from a car accident, this is deemed acceptable by Centrelink.

Regional Hospital in Victoria informed a survivor that her blurred vision and headaches was probably from stress and refused to arrange a full diagnosis. Three weeks later after colapsing at home, she was flown to the Alfred Hospital and now has a plate in her head.

Local doctors when presenting with symptoms of Traumatic Brain Injury, informing survivors that there is up to a 6 month waiting list on Medicare to have testing done. (Yet if you have a slight accident and are hospitalised and complain about headaches and blurred vision you automatically are tested.) One survivor died from a blood clot 6 weeks after assault. (2014).

Another survivor is still waiting to be tested. She spends most of her time with headaches, slight vomiting, ringing in ears, dizziness. It has been 16 weeks and she is still on waiting list for tests. (2015)

One survivor was misdiagnosed with mental illness until she was tested for another issue that resulted in confirmation she had a Traumatic Brain Injury. Now with the correct diagnosis and care plan in place she has regained her life somewhat. (2014).

So how many other survivors of domestic violence out there that have a Traumatic Brain Injury undiagnosed or untreated?

Its just not one punch that can kill.

One push (survivor had head slammed up against brick wall)

One instrument (survivor hit with cricket bat to head)

One moment (survivor fell down stairs trying to escape violence)

One fall (survivor protecting child from violence picked up child attempted to run fell on concrete path slammed head into garden bed edging lost hearing to left ear as well)

Traumatic Brain Injury and domestic violence are interlinked, both by stigma and misunderstanding.

Financial abuse not only negatively impacts the financial security of women when they are in the abusive relationship but well after they have left the abusive relationship. This leaves many women and their children in poverty and vulnerable to homelessness.

“Although there is no exact measure, research indicates that financial abuse in intimate relationships is widespread and common. It is known that a majority of women (between 80 – 90 per cent) seeking support for domestic and family violence have experienced financial abuse (Potmus et al, 2013; Sharp 2008; McDonald 2012:12).”

Family violence not only negatively impacts women’s financial security when they are in the abusive relationship, the lack of financial security continues post-separation. Many abusive men continue to financially abuse their ex-partners and exert control by abusing the courts and other government institutions such as the Child Support Agency.

“On an individual level, domestic violence creates complex economic issues for women and their children and disrupts their lives over the short and long-term. Regardless of their prior economic circumstances, many women experience financial risk or poverty as a result of domestic violence. These difficulties hamper their recovery and capacity to regain control over their lives.

In WIRE’s 2014 research report Relationship Problems and Money: Women talk about financial abuse, WIRE spoke to 59 women in focus groups about their experience of financial abuse and 145 women participated in an on-line survey.

Our findings clearly show that women’s financial security is negatively impacted in the short and long-term as a result of financial abuse.

“I had about $32,000 saved up in cash. I was working and I was working a lot, I was working a lot of hours and was doing a number of jobs going at the same time. I had plenty of money, probably for the first time I was sort of peaking in what I was earning. And also because the relationship was so abusive, my capacity to work went down as well and my income actually dropped because I wasn’t able to juggle everything and my energy levels just weren’t there.

And when I left I was about $7000 in debt and it was a bit heartbreaking because it’s so hard to save that amount of money.”

In addition financial abuse often continues even after the intimate relationship has ended.

Our findings included that for many women the financial abuse manifested itself in many ways post separation including:

• Non-payment of Child Support payments

• The perpetrator acting as a vexatious litigant causing their ex-partner to use any savings they have to fund legal costs

• Perpetrators withholding money to pressure their ex-partner into financial deals that disadvantage them in the short and long-term.

“Well my ex-husband is definitely, blatantly, obviously using the system to abuse me. Like I said I am about to go to court for the eighth time for child support. He is taking me to court. He has a [child support] debt; he won’t pay it. He is not going through the child support system because he has already appealed it and they have said no. So he is going through the legal system because he has the money and he is spending more on legal fees than the child support.

It is just a control thing and it is just about breaking me down and he is doing all sorts of things within the system to abuse me.”

The financial abuse that women experience is further compounded by the gender pay gap which amounts to women on average earning 18.2 per cent less than men. This financial abuse is exacerbated by women having to juggle work and family due to primary care responsibilities for dependent children, limiting their access to employment and in many cases to more highly paid career options.

Innovation in providing support to women who have experienced financial abuse WIRE has built on its 2007 research ‘Women’s Financial Literacy Report ’ in order to provide a gendered response to financial abuse in the context of family violence.

This approach is both preventative as well as restorative. In this research it was determined that women’s relationship with money and the societal expectations of women as poor financial managers had a significant impact in how women respond to money issues and their perception of themselves as a good financial manager.

omen repeatedly told us that their partner would ridicule their skills as a financial manager as a way of perpetrating financial abuse and using money to control them. Women often cited that it was their relationship with money and what they believed to be the cultural or community norm that made them more vulnerable to financial abuse.

WIRE’s work in this financial abuse space includes working with women and understanding their relationship with money and how perpetrators exploit stereotypes of women being poor money managers.

WIRE along with other organisations from 2011 to 2013 received funding from a variety of sources to provide workshops and financial information to women that identified as currently experiencing financial abuse.

Generally these programs had very poor reach, with few women participating. As a result of these programs not meeting expectations WIRE undertook its 2014 research, Relationship Problems and Money: Women talk about financial abuse to build knowledge and understanding of the nature and impact of financial abuse in the context of family violence, to identify the barriers that prevent women from accessing their financial entitlements and other information that would improve their financial security outcome. T

he research findings included identifying strategies to overcome these barriers. As a result of the findings from our research and through collaboration and information sharing with other organisations in the financial abuse space, WIRE is in the process of undertaking new innovative projects that take into account all new available information regarding how best to work with women who have experienced financial abuse.

WIRE’s innovation Reducing financial abuse needs to occur at multiple levels – at the preventive level as well as the recovery level. To this end WIRE is doing the following:

Prevention:

Providing information and support to women entering new intimate relationships on engaging their partner in constructive money conversations.

The project is a financial capability project rather than a financial abuse project.By working with women and providing a space for them to understand their relationship with money and build their confidence and skills to talk to their intimate partner about money issues, women have the opportunity to take action if they see the early signs of financial abuse.

The second phase of this project is yet to be funded and includes creating a website for women on having money conversations with their partner.

As a prevention strategy this project has several advantages:

o Women do not have to identify as experiencing family violence to participate.

o The project is aimed at women who are entering or have newly formed relationships and thus a relationship in which the norms are being established.

If financial abuse is indicated by the woman’s responses to assessment questions about her financial relationship with her partner, the website will inform her that what she is experiencing may be financial abuse and that financial abuse is a form of family violence, and provide information regarding where she can seek support. This once again reaches women who may not have sought assistance for financial abuse.

Reducing the impact of financial abuse: WIRE will in 2015 commence an innovative program called New Beginning: Steps to a more secure financial future.

This program aims to enable women who have experienced family violence to improve their short, medium and long-term financial security outcomes by decreasing their financial recovery time.

The project provides women throughout Victoria with financial capability support through oneon-one support and workshops. Like the Strong Beginnings- Financial Equals project this program will provide women with information to enable them to assess their relationship with money and understand the tactics perpetrators use to control women and children through money.

These workshops and support will be provided by staff who have a Definition of financial capability: Financial capability is the combination of attitude, knowledge, skills, and self-efficacy needed to make and exercise money management decisions that best fit the circumstances of one’s life, within an enabling environment that includes, but is not limited to, access to appropriate financial services, understanding of financial capability and work within a strength-based, trauma-informed and gendered framework; thus enabling the support to be tailored to the needs of women that have experienced family violence.

• Training to the community services sector: WIRE is a recognised expert in the field of financial abuse and is also a registered training organisation with a long history of providing accredited and non-accredited training to the community sector.

To enable more community sector workers to recognise financial abuse and thus take appropriate action in concert with their clients, WIRE since 2011 has been delivering professional development training regarding financial abuse in the context of family violence.

Family violence and employment “[It} was a city of 10,000, so everyone knows everyone; we were in a high profile business so that definitely had a play. I mean it had a big impact on me being able to get work because my ex-husband retained the business and it was one of the largest businesses in town and he said to me, ‘Look I have blackened your name everywhere, you won’t be able to get employment because no one will be game enough to employ you because I will pull the business away from them and no one will be game enough to hire you’ and it was true because I applied for several jobs and I didn’t even get an interview so we moved cities … So I lost my career in that my qualifications weren’t transferrable and I didn’t realise that when we split and so I lost the business and my home and our farm and all the assets but I was lucky enough to retain enough to have a house.”

•••••• Any strategies developed to protect the financial security of women who have experienced family violence must enable women to acquire decent and secure employment. We have already established in this submission that women and their children who experience family violence are far more vulnerable to poverty, financial insecurity and homelessness.

The most effective way to counter poverty is meaningful and decently paid employment. “Gaining and maintaining paid work is pivotal in creating a secure financial future for victims of domestic violence and their families.”

However, participation in employment can be seriously undermined by ongoing abuse and its subsequent effects. Australian researchers, for example, found that some women had not been allowed to work while in a violent relationship and found it difficult to enter or re-enter the workforce post separation.

These findings are echoed in overseas studies, which highlight how domestic violence not only acts as a barrier to education, training, and employment but also can escalate when survivors seek or participate in such activities. In order to maintain control over their partners, abusers may interfere with women’s efforts to become self-sufficient.

Women affected by domestic violence are also more likely to have a disrupted work history and are more likely to occupy casual and part-time work than women with no experience of violence. In short, women escaping and experiencing domestic violence are often the most disadvantaged and vulnerable in the labour market.

Some researchers argue that the dominant approaches to domestic violence in Australia have been crisis oriented and focused on providing accommodation, welfare assistance, and emergency support services to women and children without looking towards job search and training to facilitate financial security independent of social service agencies.”

National Domestic Violence and Workplace Survey (2011) noted that two thirds of family violence survivors are in paid employment. This statistic highlights the importance of enabling women affected by family violence to continue their employment.

Apart from providing crucial financial security, employment often also provides support networks to women who are experiencing family violence. This strategy aimed at retaining women in employment is critical. The ACTU is presently running a case to insert Domestic Violence Clauses (including paid leave) into Modern Awards.

As of November 2013 over 1.2 million workers in Australia now have access to paid Family Violence leave. WIRE supports all employers incorporating the ACTU’s Domestic Violence Clauses into their industrial Agreements and policy documents. Some women may need to give up their employment to escape their abuser; others may not have had an opportunity to work whilst in an abusive relationship.

Thus many women who have experienced family violence will require additional assistance finding employment. Assistance provided to women who have experienced family violence needs to incorporate job search expertise, a strengths based approach to working with women and additionally have a strong understanding of the impact of family violence on women and children.

WIRE runs weekly job coaching for women. Often women who have experienced family violence attend job coaching to get support and advice on how to find employment.

Women who have experienced family violence often present to job coaching with multiple barriers to overcome which includes but is not limited to:

For women that have had to change their identity as a safety measure, they are not able to demonstrate a work history or provide referee details or written references to prospective employers.

Many women in abusive relationships are prevented by their abusive partner from working and earning an independent income, and thus they do not have a recent work history.

Many abusive men isolate their partners in order to exert control.

Over time the woman’s network diminishes, leaving the woman with few networks to utilise to find employment.

Women that have accessed security and housing in a family violence refuge must give up their usual routine – this includes any employment they may have had prior to leaving the abusive relationship.

Women are placed in refuges away from their local community; for some women this means moving from the city to a regional centre or vice versa. Maintaining employment in these circumstances is exceedingly difficult.

Women in abusive relationships can have a poor work history as a result of their abusive partner using control tactics which prevent the woman from keeping her job.

Examples of these tactics include:

Taking away the woman’s access to transportation to work

Refusing at short notice to care for children

Stalking the woman at work so that she is unable to perform her work

Women often report being psychologically exhausted by the violence and intimidation to the extent that they had difficulty holding down a job.

Women have increased absenteeism from work as a result of psychological and physical injuries inflicted on them by an abusive partner. These unexplained absences from work are often interpreted by an employer as the woman not caring about their job and being unprofessional. As a result women may lose their jobs.

Women’s confidence is greatly affected by the controlling, disrespectful and undermining behaviour of their abusive partner. This reduced confidence also manifests itself when women are looking for work.

• Women who have experienced financial abuse to have access to timely and extensive financial counselling and support, that involves exploring women’s relationship with money and the impact that social stereotypes, family and upbringing may have had on a woman’s confidence in financial decision making.

• Women who have experienced family violence having access to specialist employment programs that include but are not limited to intensive job search support and job matching programs.

• That all employers including the State government make available in their industrial agreements and policy documents the ACTU’s Domestic Violence Clause provisions. Increasing the effectiveness and accessibility of family violence services

Effective response: women accessing family violence support during their recovery phase The effects of family violence do not end when the abuse ends. The road to recovery can be a slow holistic process that encompasses emotional, physical and financial wellbeing.

“I wake up in the morning and I feel physically sick and I think, ‘Where do I start?’ I wake up every morning and I vomit in the shower.” ••••••• -describing having to cope with extreme poverty well after leaving the abusive relationship. -is unable to find work, struggles to find affordable accommodation and provide food for herself and her daughter.

Why doesn’t she just get over it? Unfortunately this is still a question asked by many in the community. The vast majority of family violence practitioners and services understand that the trauma women experience when subjected to family violence often leaves women with deep emotional, psychological, financial and physical scars.

Even so, many family violence services do not have the resources to provide these women with a service. Women that have not received assistance from family violence services at the point of leaving have increased difficulty accessing family violence specific services down the track.

This may be because their needs are viewed as being less critical than women that are at the point of leaving (one of the most dangerous times for women and children in abusive relationships), and most definitely due to the pull on resources to keep women and children that are deemed most in danger, safe.

Not all women will contact family violence services for assistance at the point of terminating an abusive relationship. Some will only seek assistance when particular flashpoints occur after the woman has left the abusive relationship; and others may seek assistance from the point of separation and as flashpoints occur post separation.

Examples of flashpoints include:

Ex-partner begins to stalk physically or electronically

The woman faces a housing crisis

There is a recurrence of violence or the threat of violence from their ex-partner Ex-partner moves to a location close to the woman and her children

The woman becomes aware that the ex-partner is trying to locate her

There is an issue regarding child maintenance payments

Court hearings

The woman is feeling an emotional strain which is causing her difficulty with functioning at some level.

WIRE speaks to many women that have tried to access family violence services at these flashpoints. They often tell us that once the family violence service has conducted a safety screening, they are told that due to the number of women in crisis, their situation is not considered a priority.

For many women, the experience of being told that they are not a priority or their situation is not serious enough gives the message that they are on their own and they have failed to ‘just get on with life’. Due to lack of resources and the high demand from women, family violence services are compelled to triage women requests for service.

We need to move to a system that is able to assist women not only at the point of crisis but throughout the recovery and rebuilding process.

Family violence services should:

utilize trauma-informed practice

have a strengths based approach

enable women to receive support for the long-term effects of family violence

take into account that some women may require long-term support, others short-term and/or episodic support

recognise that the experience of family violence makes women and their children more vulnerable to homelessness, financial insecurity, and continuing emotional distress; and that this vulnerability can exist for years after the woman has left the abusive relationship.

Proactively reaching women WIRE receives calls from women who have been told by police that they would be contacted by a family violence service, but this contact has not happened.

With the police attending 65,000 incidences of family violence last year WIRE is very aware that family violence providers throughout Victoria are overwhelmed by the increased numbers of L17s.

This is resulting in those services having to prioritise the L17s that they respond to first and the method by which they respond. For some women being told by the police that they will be contacted by a family violence service is their first experience of family violence support services and when that assistance does not materialise it is disappointing and discourages further contact with support services.

The introduction of L17s has been highly beneficial.

It has enabled family violence services to be proactive and contact women who would not have otherwise contacted a family violence service. This has often led to women and children leaving abusive relationships earlier with the assistance of specialist services.

Timely and proactive intervention by family violence services to women involved in family violence incidences attended to by police is a crucial element of Victoria’s family violence response and as such must be appropriately funded.

Recommendations for increasing the effectiveness and accessibility of family violence services:

That services that manage L17s are provided with additional funding so that they can act on the L17s within a reasonable time frame.

Women have access to family violence specific services and are able to engage with the family violence service delivery system on a short-term, long-term or episodic basis.

That family violence specific services are funded to support women who have experienced family violence related trauma and have ongoing issues as a result of the family violence they experienced, and this includes providing evidence-based family violence recovery programs and making support available to women.

Holding perpetrating men accountable for their actions In our community and in our institutions, the responsibility to manage family violence is often left to the women who are experiencing the violence.

It is the woman that holds the responsibility for ending the violence. This culture of blaming the victim needs to end. The culture of blaming the victim enables the perpetrator to have his behaviour excused and tolerated. It must be the individual perpetrating the violence that faces the consequences of their actions at every level of society. T

his includes at work, sporting clubs, churches, schools and in the justice system. All too often women must leave the family home to end the violence. This relocation often results in women losing their jobs and social networks, and removing their children from schools and friendship networks. The loss associated with having to relocate is a significant barrier to leaving an abusive relationship.

Women and children leaving an abusive relationship face a significant risk of homelessness. Women carry the financial burden of ending an abusive relationship. Women who have violent partners find their options are limited to either living with violence, or living in poverty and facing potential homelessness. The choice is not an enviable one.

The perpetrator is often very aware that their partner’s options are limited and uses this to further control the behaviour of their partner.

There are many ways to reinforce that perpetrating men are responsible for their violent and abusive behaviour, and that they will be held to account and experience negative consequences.

Recommendations to hold perpetrating men accountable for their actions:

That the legal system and family violence sector continue to reinforce the concept that the perpetrator should be made to leave the family home, and not the victim

That the perpetrator has financial responsibility for the child raising costs of their children including contributing to accommodation costs after the perpetrator has been removed from the family home

That rent concessions are available to women who need assistance paying rent for the family home after a perpetrator has left. This enables the woman and her children to remain in the family home.

That banks and financial institutions have trained staff to work with women who have experienced family violence, so that debts including mortgages can be renegotiated to assist the women to continue living in their family home.

Perpetrating males who do not have alternative accommodation are relocated to group dwellings where men’s behavioural change programs are compulsory.

All men that are charged with family violence related offences are mandated to attend family violence specific behavioural change programs.

Where appropriate, perpetrators have ankle bracelets to track their movements

All women who have experienced family violence have access to financial support so that they can make their house more secure, for example with CCTV cameras and new locks.

Women having access to workplace entitlements that will support them to continue their employment. This includes paid time to manage their family violence situation.

That if work equipment such as a work phone or car is used to commit an act of family violence even if it is not considered an act in which criminal charges can be laid that the perpetrator will be disciplined by the employer.

If the perpetrator and the victim have the same place of employment, the perpetrator must alter their work patterns to accommodate any Apprehended Violence Orders (AVOs).

Submission to the Royal Commission into Family Violence (Victoria) WIRE Women’s Information and Referral Exchange Inc.

That from kindergarten upwards within our education system, children are taught appropriate conflict resolution strategies and explicitly taught that family violence is not tolerated and the actions of the perpetrator are never justified.

“I am still paying off the debt 15 years after leaving.

Participant of WIRE’s Relationship Problems and Money

Women talk about financial abuse research 2014 Financial abuse is a form of family violence recognised by the Family Violence Protection Act (2008).

This was first published by WIRE as their submission to the Royal Commission of Family Violence 2015.

This article examines the research findings of the SmartSafe study conducted by the Domestic Violence Resource Centre Victoria (DVRCV). With this study, we aimed to examine technology-facilitated stalking in the context of domestic violence in Victoria, Australia. Stalking is a prevalent crime in Australia, with one in every five women over the age of 15 reporting they have been stalked (Australian Bureau of Statistics, 2006).

Contrary to popular misconceptions, research shows that the majority of stalking is perpetrated not by strangers or acquaintances but by intimate partners or ex-partners (Spitzberg & Cupach, 2007). Evidence demonstrates that men are the main perpetrators of intimate partner stalking, both in Australia and internationally (Kuehner, Gas, & Dressing, 2012; Logan & Walker, 2009; Strand & McEwan, 2011). Reviews of international research demonstrate that women are more likely to be stalked than men (Logan, 2010; Spitzberg & Culpach, 2007), and are more likely to experience fear due to stalking (Sheridan & Lyndon 2010). In this study, we focused upon an emerging trend in intimate partner stalking in the context of domestic violence: the use of technology to facilitate stalking and other 2 forms of abuse.

Research studies on technology-facilitated stalking in the context of domestic violence are limited (Dimond, Fiesler, & Bruckman, 2011; Hand, Chung, & Peters, 2009). Therefore, we conducted a scoping study to determine (a) whether technology-facilitated stalking is an issue for women experiencing domestic violence and (b) whether mobile technologies (such as smartphones) present further opportunities for the perpetration of stalking and domestic violence against women. To ground the study, we first review previous studies on intimate partner stalking in general and then explore the available empirical research on technology-facilitated intimate partner stalking.

What is Intimate Partner Stalking? Stalking encompasses a pattern of repeated, intrusive behaviors—such as following, harassing, and threatening—that cause fear in victims (Logan & Walker, 2009). In the context of domestic violence, stalking tends to be an abusive behavior that perpetrators employ to control the victim after the relationship has ended. 2 (Hand, Chung, & Peters, 2009; Logan, Leukefeld, & Walker, 2000). However, stalking behaviors often occur as part of the relationship before separation (Cox & Speziale, 2009; Melton, 2007). Stark (2007) argues that intimate partner stalking is a form of coercive control.

Coercive control is a theoretical framework that encompasses physical abuse that occurs in domestic violence, but which also includes tactics not traditionally viewed as serious forms of abuse. These tactics include strategies to control and intimidate, such as isolation, surveillance, threats of violence, micromanagement of daily activities (e.g., regulation of showering and eating) and shaming (Stark, 2007). The theory of coercive control also encompasses the effects on the victims of these tactics.

Stark (2012) believes these effects have more in common with the experiences of hostages and the victims of 3 kidnappings than of victims of conventional assaults. Stark (2012) acknowledges that although women can be abusive in intimate relationships, men are the main perpetrators of coercive control because it is a form of violence rooted in systemic inequality, which affords men a sex-based privilege. Stark (2012) views this sex-based privilege as the essence of coercive control, where male offenders “exploit persistent sexual inequalities in the economy and in how roles and responsibilities are designated in the home and community to establish a formal regime of domination/subordination behind which they can protect and extend their privilege[ ]” (p. 206).

Stalking by intimate partners is a risk factor for serious violence—including sexual violence and homicide—but it is often not taken seriously (Scott, Lloyd, & Gavin, 2010). An Australian study found that police and many community members perceive intimate partner stalking as less serious than stranger stalking (Scott et al., 2010). However, research suggests that those who stalk their partners are particularly persistent and dangerous (Tjaden & Thoennes, 1998, p. 12). Intimate partner stalking can occur for many years, often continuing for longer periods than stranger or acquaintance stalking. A national U.S. survey found that cases involving stalking by intimate partners lasted 2.2 years on average, compared with 1.1 years for stalking by others (Tjaden & Thoennes, 1998, p. 12). Intimate partner stalking is also distinct from non-partner stalking due to the use of a wider array, and more frequent, stalking tactics, a heightened risk of threats and violence as well as greater psychological distress for the victim (Logan & Walker, 2009).

Intimate partner stalking has been linked to an increased risk of homicide; one study found that 68% of women experienced stalking within the 12 months prior to an attempted or actual homicide (McFarlane, Campbell, & Watson, 2002, p. 64). The most 4 frequent types of intimate stalking behaviors preceding attempted or actual homicides include following or spying, making unwanted phone calls, and keeping the victim under surveillance (McFarlane et al., 2002).

Technology-Facilitated Stalking and Abuse in the Context of Domestic Violence The first organization to highlight the use of technology in domestic violence was the Safety Net Project, which started in 2002 in the United States (Fraser, Olsen, Lee, Southworth, & Tucker, 2010; Southworth, Dawson, Fraser, & Tucker, 2005). Both Fraser et al. (2010) and Southworth et al. (2005) emphasize that mobile technologies can be useful tools for victims, enhancing their safety and assisting in recovery from abuse. However, Fraser et al. (2010) argue that technology can provide perpetrators with more tools and greater scope to intimidate and control their victims.

The effect of repeated phone calls and text messages on a victim’s life should not be underestimated. Fraser et al. (2010) contend that harassing and unwanted calls and text messages create a pattern of stalking tactics that aims to control the victim. Some perpetrators text and phone repeatedly, creating dread and fear in the victim that the harassment will never end. Some women receive only one text or call daily or weekly, but this can be equally as terrifying in the context of their specific domestic-abuse history. Hand et al. (2009) discuss the potential misuse of information and communication technologies (ICTs) by perpetrators of domestic violence in Australia. Referring to Stark’s (2007) work on coercive control, the authors argue that ICTs can provide further opportunities for controlling women, enabling perpetrators to abuse women in new and more-extensive ways.

These include placing a woman under surveillance, which Hand et al. argue could erode her sense of “feeling safe” (p. 3) after leaving a violent relationship. 5 There is little published empirical research on the use of technology in intimate partner stalking. In a large U.S. study on stalking, 25% of stalking victims reported being stalked via technology, such as e-mail (Baum, Catalano, Rand, & Rose, 2009). Fraser et al. (2010) note that, in line with evolving technologies, this percentage is now likely to be higher and increasing.

Two studies of university students in the United States found that technology is commonly used to monitor, control, or harass an intimate partner (Burke, Wallen, Vail-Smith, & Knox, 2011; Melander, 2010). Burke et al. (2011) examined the use of technology to monitor and control intimate partners in a sample of 804 undergraduates at a U.S. university.

The study found that half of both female and male participants were either perpetrators or victims of technology-facilitated abuse. Of female college students, 25% self-reported that they monitored their partner’s behavior by checking e-mails compared with 6% of male students. Female students reported receiving repeated threatening, harassing, or insulting e-mails and/or instant messages, with 10% to 15% experiencing this behavior from their partner. Males were more likely than females to use hidden cameras and global positioning systems (GPS) to control and monitor their partner, with 3% of males using hidden cameras compared to .4% of females, and 5% of males using GPS and 1% of females (Burke et al, 2011, p. 1166).

Melander (2010) used focus groups to examine intimate partner cyber harassment among 39 college students in the United States. Melander (2010) found that students were using technology, such as mobile phones and social networking sites, to control intimate partners.

Controlling behaviors included monitoring a partner or ex-partner via technology, such as GPS tracking, or constantly texting and harassing the victim for his 6 or her location. Participants perceived constant texting, in general, as a form of control and intimidation. Melander emphasizes that because of technology, perpetrators were able to maintain control over their victims, even when they were in a different location.

Technology provided perpetrators with quick, easy methods to harass and abuse, and this behavior was often more public. As one participant wrote, “You can make it sting a lot more,” particularly when using social media to intimidate and embarrass a partner or expartner (Melander, 2010, p. 266).

There are limited studies into the use of technology to share, or threaten to share, sexually explicit messages or images (known as “sexting”) in the context of domestic violence. Sexting can be defined as “the creating, sharing, sending or posting of sexually explicit messages or images via the internet, mobile phones or other electronic devices by people, especially young people” (Law Reform Committee, 2013, p. 19).

An inquiry into sexting reported examples of the use of sexting in domestic violence (Law Reform Committee, 2013). Anecdotal evidence provided to the inquiry revealed that perpetrators are using mobile-phone images and videos of women, provided consensually or coercively, to threaten, harass and control victims of domestic violence (Law Reform Committee, 2013, p. 24). A qualitative study conducted by Ringrose, Gill, Livingstone & Harvey (2012) focused on sexting, in general, among young people in the United Kingdom.

Their research found that sexting is often coercive and linked with harassment, and sometimes violence, against young women. In a U.S. study into technology abuse among teenagers, more than 10% of the participants said that a partner had shared a private picture of them, 20% said they had been asked via technology (e.g., the Internet or a mobile phone) to 7 engage in unwanted sexual activity (Picard, 2007). Similarly, a large-scale study in the United States (Zweig, Dank, Lachman, & Yahner, 2013) found that teenagers in relationships were being sexually abused and coerced via technology. Girls reported being victims of technology abuse at a higher rate than boys, with 29% of girls reporting abuse and 23% of boys. This difference was increased when the reported abuse involved sexual behavior. Approximately 15% of girls reported sexualized technology abuse, compared with 7% of boys (Zweig et al., 2013).

In one of the only studies on the experiences of technology-facilitated abuse among victims of domestic violence, Dimond et al. (2011) interviewed 10 women at a domestic-violence shelter in the United States. The researchers found that perpetrators are using GPS as well as location-based features on Facebook to track women. The women also reported being threatened via text messages that were difficult to block.

The women spoke of the challenge in maintaining their safety when using social media such as Facebook, because when friends tagged3 them in photos, the privacy of their location could be compromised. Although the authors argue that more research is needed into the ways in which perpetrators use technology to control and abuse women, they emphasize that victims should have the right to safely access technology, which can enhance their connections with friends and family. THE SMARTSAFE STUDY The SmartSafe study was an initiative of the DVRCV, one of the first domestic-violence organizations in the world to have online resources for victims.

The DVRCV has continued to use technology to prevent domestic violence for more than 15 years. Our work has included websites focused on young people and healthy relationships, YouTube videos, blogs and online quizzes.

Our central aim with the SmartSafe study was to 8 examine how mobile technologies provide additional opportunities for the perpetration of stalking and domestic violence against women.4 Although we considered all technologyfacilitated stalking, we focused in particular on smartphones, which are mobile (or ‘cell’) phones with Internet access, GPS, and video capability.

Studies show that people are increasingly using mobile devices rather than computers to access the Internet, particularly for the purposes of social media (Dudley-Nicholson, 2013).

Given the limited research in the area of technology-facilitated stalking and domestic violence, we designed this study as an exploratory scoping project. Our aim with this research was to assist practice, provide awareness, and increase knowledge for workers in the domestic-violence sector, our goal ultimately being to improve outcomes for women experiencing violence. We used a multiple-methods approach, which included focus groups, two online surveys, and interviews.

In this article, we focus on the results from two online surveys; the first was a survey of workers in the domestic-violence sector (worker survey), the second a survey of women who had experienced intimate partner stalking (victim survey). We designed the survey questions in consultation with domestic-violence crisis workers.

The two surveys included closed and open questions, a form of multiplemethods research that captures quantitative and qualitative data (Erickson & Kaplan, 2000). Our purpose with the worker survey was to discover the practice experiences of workers in the domestic-violence sector in Victoria. The worker survey examined intimate partner stalking in general, technology-facilitated stalking, and workers’ experiences of the legal response to stalking. 9

Based on the results of the worker survey and consultations with domesticviolence refuge workers, we developed the survey for victims. The worker survey indicated that many women do not identify stalking behaviors as stalking. Therefore, our aim was to include women who may not have encountered domestic-violence services or who may have been unsure whether behaviors they had experienced could be defined as stalking.

Therefore, in the recruitment materials, we used the term unwanted contact rather than stalking, emphasizing that this unwanted contact resulted in women feeling fearful.6 Some of the survey questions were based on research studies on technology and abuse (Picard, 2007). Convenience sampling was utilized in the research. We advertised the victim survey on the DVRCV website, Facebook, Twitter, and gumtree.com.au, a local classified-advertising and community site. In addition, we displayed posters at universities and in health centers.

The survey for workers was conducted from August to October 2012, and the victims survey was open from October 2012 to December 2012. We used NVivo to code the answers to the open questions in the two surveys and used thematic analysis to categorize the findings (King & Horrocks, 2010; Saldaña, 2012). Applying the system of thematic analysis as outlined by King and Horrocks (2010, p. 152), we first coded the survey answers descriptively. Next, we applied interpretive coding to the findings, where meaning was interpreted according to the research question and theoretical framework of coercive control (Stark 2007).

Three interpretive themes emerged in relation to the ways in which perpetrators use technology in the context of domestic violence:

(1) to create a sense of omnipresence,

2) to isolate, and

(3) to punish and humiliate.

These codes were tested for reliability and validity through consultation with workers and researchers in the field of domestic violence. To 10 substantiate the validity of the analysis development, we maintained an audit trail of the research processes. The final stage of thematic analysis is to define overarching themes (King & Horrocks, 2010, p. 154).

Given that this research was a small-scale scoping study, we identified only one overarching theme from the data. This theme—control and intimidation—is the outcome of the various tactics that are used by men, according to the research findings. Although the tools and technologies used by the men were diverse, their tactics were analogous in their impact on the lives of the victims.

The women were controlled and intimidated by the men’s behavior. Profile of Participants In total, 152 workers in the domestic-violence sector in Victoria participated in the worker survey. They worked in a variety of roles, including case management, crisis response, housing, and legal support. The average length of time working in the sector was 5.5 years.

In total, 46 women participated in the victim survey. The average age of the women was 35 years. The survey included self-identifying open questions about cultural background, sexuality, family, and disability. Of the participants in the victim survey, 92% identified as Anglo-Australian, 91% as heterosexual, 9% as bisexual, 9% as having a disability, and 37% as a parent with children.

RESULTS: CONTEXTUAL FINDINGS

To understand the ways in which technology-facilitated abuse is situated in the context of domestic violence, we included survey questions that would provide us an insight into the 11 lives of women experiencing technology-facilitated stalking. In the following section, we present a profile of a woman experiencing technology-facilitated stalking.

The worker survey asked about the types of technologies workers were aware of perpetrators using for the purpose of stalking women in the context of domestic violence. The results showed that the three most commonly used technologies are smartphones at 82% , mobile phones at 82% and social media (such as Facebook) at 82% .

These results correspond with the results of other studies on intimate partner-stalking behavior, which have found that women are most likely to be stalked via their phone (McFarlane et al., 2002, p. 64).

However, the high percentage of women being stalked via social media indicates a shift in the methods that perpetrators are using to stalk women. The results of the worker survey indicated that women are being stalked via additional forms of technology, including e-mail at 52% and GPS at 29% . The victim survey asked participants to select the specific ways in which mobile technologies had been used to stalk them.

Their responses show that text messaging is the most common form of technology-facilitated abuse used against women.

In a study of intimate partner cyber harassment among college students, Melander (2010) found that young women were receiving excessive numbers of text messages, which they experienced as a form of control.

Purchased a phone for her for the purpose of keeping track of her Gave a phone or other device to their children to create further opportunities to contact her against her wishes.

In the victim survey, participants were asked whether they had experienced other forms of domestic violence in that relationship. The survey findings show that women who experience technology-facilitated stalking are also likely to experience other forms of domestic violence within the same relationship. Eighty-two per cent of participants had experienced emotional abuse, 58% sexual abuse, 39% physical violence, and 37% financial abuse.

These findings are consistent with other studies, which show a link between intimate partner stalking and other forms of domestic violence (Krebs, Breiding, Browne & Warner, 2011) and between intimate partner stalking and emotionally abusive or controlling behavior (Tjaden &Thoennes, 1998).

In addition, emerging research shows a link between stalking and sexual violence (Logan & Cole, 2011). Participants in the victim survey were asked if the unwanted contact had affected their mental health and wellbeing. Of the 39 who responded to this question, 84% (n = 33) said it had. Recent U.S. research focusing on the effect of intimate partner stalking on women’s psychological wellbeing found high levels of emotional distress and antidepressant use among women (Kuehner et al., 2012).

A large-scale population study 14 conducted in Australia found that stalking is one of the most common forms of violence against women and, as with other forms of gender-based violence, stalking affects women’s mental health (Rees et al., 2011). The victim survey included questions about the women’s help-seeking strategies. We were careful to phrase these questions to avoid appearing to attribute responsibility to the women.

The survey findings show that a woman experiencing technology-facilitated stalking is unlikely to seek help, with 56% (n = 26) of participants indicating they had not sought assistance. The main reason women gave for not seeking help was their embarrassment about the abuse, with 85% (n = 22) stating they were too embarrassed to seek assistance. This is in line with other studies, which show that many women feel shame about the violence they are experiencing (Fanslow & Robinson, 2004; Logan, Shannon, Cole, & Walker, 2006).

This kind of shame is common among victims and is often a significant barrier to seeking help (Rose et al., 2011). In addition, it is important that embarrassment be understood as part of the tactics used by stalkers, who often deliberately isolate and shame women (Fugate, Landis, Riordan, Naureckas & Engel, 2005). For the 44% (n = 20) who said they had sought help, 77% (n = 15) had spoken with their family or friends, and 44% (n = 9) had spoken with domestic-violence services.

This is consistent with research conducted by Logan, Shannon, et al. (2006) that found that most women who experience stalking and seek help do so from family and friends, with fewer seeking help from domestic-violence services, the police, or legal services.

TACTICS USED IN TECHNOLOGY-FACILITATED STALKING

The material in this section is drawn from the survey responses to questions related to technology-facilitated stalking.

The relevant question in the worker survey was, “Could 15 you provide examples that you have encountered in the course of your work of how technology has been used to stalk/harass/abuse women?” In the victim survey, a closed question asked participants about the ways in which a partner or ex-partner had used technology to contact them in a way that had made them fearful.

Participants were given the opportunity to provide more details about their experiences if they felt comfortable to do so. Using the statistical findings of the closed questions to guide us to the most significant findings, for example, the high number of women who said that social media was used by perpetrators, we then thematically analyzed the responses to these questions to provide more-comprehensive insights into the ways in which stalkers use technology in the context of domestic violence.

Omnipresence According to Stark (2012, p. 25), stalking “is the most dramatic form of surveillance used in coercive control … [and] falls on a continuum with a range of surveillance tactics whose aim is to convey the abuser’s omnipotence and omnipresence.” A major theme that emerged from the findings of the SmartSafe study is the way in which perpetrators use mobile technologies to create a sense of being ever-present in the victim’s life.

Fraser et al. (2010, p. 44) write that “one of the more terrifying tactics used by stalkers is to make the victim feel that she has no privacy, security, or safety, and that the stalker knows and sees everything.” The results from both surveys indicated that perpetrators do employ this tactic and that mobile technologies enable perpetrators to be omnipresent in ways not previously possible.

This tactic erodes the spatial boundaries of the relationship; although a woman may have physically separated from her partner, she is unable to completely escape his presence in her life (Dimond et al., 2011; Hand et al., 2008). 16 The results of the two surveys showed that the most common way perpetrators created a sense of omnipresence was via constantly texting and/or phoning their victims. Domestic-violence workers reported that constant text messaging and phoning are particularly harmful to victims, because these behaviors create the feeling that she cannot escape the perpetrator.

One worker wrote, “Texting is a big problem. The ease of access means that even if someone can remove themselves physically from an abusive situation, it is very hard for them to remove themselves psychologically.” The way in which technology enables this ease of access is highlighted by Hand et al. (2009) who argue that spatial boundaries of security for women leaving domestic violence have shifted due to the global reach of mobile technologies.

Workers specifically mentioned that perpetrators know women have their phones with them at all times and are abusing them with text messages 24 hours a day: The concern is that with mobile technology, stalking can occur 24 hours a day no matter where the person is.

For one of my clients with an intellectual disability, having messages left on her phone or even missed calls was distressing to her because it brought the situation into her mind repeatedly and she was upset whenever her phone rang. Victims, too, wrote of the effect of constant text messages and of the consequent feeling of being trapped: “My ex would text me over 50 times a day and would make me feel like I was constantly under surveillance. He stalked me for a year after I left him.”

Another victim wrote, “He would constantly text me to check up on me during our relationship. This behavior escalated when we broke up. I would get over 100 abusive texts a day—I never felt free of him.” 17 An additional key finding was the use of GPS mobile technology to engender this sense of omnipresence. Perpetrators usually achieve this by downloading mobile applications (“apps”) to women’s phone or hiding a GPS device in their vehicles.

A participant in the worker survey illustrated the numerous ways in which perpetrators use GPS: A past client was under a great array of electronic surveillance. Her ex-partner had installed a tracking device in her car and would text her and let her know that he was aware of her location.

She had the GPS disabled on her phone, but this persisted. Also, after engaging a person to repair the front gate, it was discovered that her ex-partner had installed covert cameras both in the home and at the front gate that he had linked to his computer. Evidently, in the above example, the perpetrator wanted the woman to know that she was under surveillance.

Stark (2012) asserts this is a key tactic men use to intimidate and instill fear. Some perpetrators were overt about their tracking, but some participants in the victim survey wrote of suspecting they were being covertly monitored: I suspect he may have installed software onto my iPhone enabling him to have access to my phone calls, text messages, Facebook, e-mails, etc.

He sometimes says things or behaves in ways that suggests he knows something via a suspicious means. Being under surveillance can make it difficult for women to leave the relationship safely.

One victim wrote, “My ex used to track me with GPS; I felt afraid to tell him to stop doing this. This made it so hard to leave him.” Although disenabling location tracking or removing GPS devices may appear simple solutions to this form of 18 surveillance, doing so can often be dangerous for women because it can alert the perpetrator to the possibility that she is leaving the relationship. According to Fraser et al. (2010, p. 55) disenabling location tracking can increase the risk of an escalation of violence as the abuser attempts to regain control over the victim.

Perpetrators use additional forms of technology to track women and generate the impression that they know and see everything. Workers and victims wrote of perpetrators using social media, specifically Facebook, to relentlessly monitor and abuse women.

Even when a woman blocks her partner or ex-partner from her Facebook account, he may continue to monitor her through the Facebook pages of shared friends, family, or even their children. 8 One worker wrote, “I have had two clients who have relocated and changed their names but [who] have still been found by [the perpetrator] stalking the client’s friends on Facebook.”

Facebook’s focus on creating friendship networks enables perpetrators to track women through friends and family, particularly when friends tag women in photos or at events. According to one worker: Women “check in” on Facebook so others can see where they are at any given time. People tag these women in photos or at events so that others can see where they are [and] what they are doing.

Stalkers can follow friends, family, and acquaintances, so that even if the women are not friends with them [the stalkers], they can still see what they are doing. Workers identified Facebook as a platform that perpetrators use to proxy stalk women. Proxy stalking refers to a perpetrator using other people to contact the victim (Melton, 2007).

One worker wrote, “Offender and his family members are using social 19 media to keep up to date on partner and children.” Participants in the victim survey noted that perpetrators were using other forms of proxy stalking; for example, several women mentioned receiving constant text messages from the perpetrator’s family and friends. This may heighten a woman’s feelings of isolation by conveying the impression that the perpetrator does not need to be present to control her; he can monitor her via other people and, in so doing, create the impression that no matter where she goes, she will not be safe from him. Melton (2007) argues that a woman may find proxy stalking more terrifying than other forms of stalking, because it involves numerous people following and tracking her.

Isolation Stark (2012) argues that perpetrators isolate a partner to instill dependence, to monopolize their time, and to prevent them from getting help. Perpetrators isolate victims from their support systems by abusing and harassing the victim’s family, friends, and coworkers; restricting the victim’s contact with others; and embarrassing the victim in front of family and friends (Stark, 2012).

This isolation often results in victims having little or no support systems (Arnold, 2009). Logan & Walker (2009, p. 259) state that stalking can create various forms of social isolation; for example, women may need to relocate or change their employment to avoid stalkers.

The authors also note that a stalker can sabotage, directly or indirectly, a victim’s relationships with others. The use of isolation to control and intimidate women emerged in the SmartSafe study. Perpetrators use technology to isolate women from their support systems, through either direct or indirect harassment of friends and family. Direct harassment includes means such as text messages, phone calls, and Facebook. Indirect harassment includes 20 women changing their phone numbers, closing their Facebook accounts, or relocating due to the constant abuse.

The surveyed workers wrote of the effect on victims’ lives of changing their phone numbers: “Women who change their phone numbers to prevent perpetrators contacting them disadvantage themselves to services because they become uncontactable, e.g. to be notified regarding housing offers, etc.” This is significant because women who are being harassed via their mobile phones are often advised to change their mobile phone number.

However, to do so can result in a significant increase in the social isolation many women experience during domestic violence (Fraser et al., 2010). One victim wrote: I tried to block his number, but I didn’t want to change my number, as I didn’t want him to impact me in that way. Eventually, I did have to change all my numbers, which was sad, but I couldn’t take it any longer. Victims also wrote of having no choice other than to relocate to escape the perpetrator: “He harassed my family to try to find me with constant phone calls, but I have moved states (losing contact with most of my supports) to be free of him.”

Another victim wrote, “My partner used to call my family to leave threats, ask questions, etc. He would sit outside my house [and my] work until I got him arrested. I have had to move states just to feel safe.”

One surveyed worker described the lengths a perpetrator went to in an attempt to maintain control over a victim and the way in which technology assisted this abuse: My client fled from another country to Australia due to domestic violence, but her ex-partner located her through Facebook and began sending threatening messages 21 to her in Australia.

He migrated to Australia to continue harassing, stalking, and abusing her. He gained access to her mobile phone in order to monitor her contact with services, friends, etc. This worker’s story clearly illustrates the possibilities mobile technologies offer perpetrators. The potential for global reach is evident, and the effect on the woman’s life was multi-faceted; not only could she not escape him (he was able to track her internationally) but also he was able to control and isolate her, monitoring her contacts and abusing her friends and family.

The way in which perpetrators use social media, such as Facebook, to publicly harass women and the effect this has on women’s social networks was emphasized by the surveyed workers. One wrote, “Facebook and Internet stalking and abuse have increased. Things are being posted online about women, such as rumors or allegations and they [are] unable to defend themselves.

They lose a lot of social supports through this process.” The intent appears to be to damage women’s relationships with others and to embarrass women, which Stark (2012) argues is a key tactic perpetrators use to isolate women and control them.

This can also be seen in a surveyed worker’s account of a perpetrator using Facebook to locate a victim and impersonate her: My client’s ex-partner has tracked her down after following her Facebook use. He assaulted her, stole her phone, and accessed her Facebook [account]. He has changed her passwords, and she is now not able to access her own account. He is contacting all her friends and supports, pretending to be her.

This has resulted in her becoming very isolated. He has allegedly sent sexual messages to male friends 22 in her account, resulting in the client feeling ashamed and powerless. The client has reported the incident, but police have not been able to find the respondent. As the worker notes, the powerlessness of the victim to stop the public harassment is not only isolating but also shaming.

The perpetrator appears intent on disconnecting the woman from her social supports. This example highlights the ease with which this can be achieved through social media. Punishment and Humiliation The third major theme that emerged from the research findings is the use of technology to punish and humiliate. Stark (2012, p. 25) writes that perpetrators often say or do things in a public setting to insult or embarrass victims, usually as a tactic to silence them. An intimate partner stalker often knows his victim’s greatest fears, concerns, and secrets, and uses this knowledge to punish, torment, and humiliate her (Logan, Walker, Cole, & Shannon, 2006, p. 26).

Perpetrators have long used this tactic, but mobile technologies enable them to use it with ease and immediacy—broadcasting humiliating content to friends, family, and the community (Fraser et al., 2010). Participants in both surveys reported the use of technology to share sexualized content as a tactic perpetrators use to humiliate women.

Participants provided numerous examples of non-consensual sexting. One victim wrote, “He must have set up cameras somewhere in the house, as he had naked photos of me that he threatened me with.”

Another woman was threatened with the release of images, which she was unsure actually existed: “Secretly filmed things (possibly) and threatened to send them.” As discussed, some of the women who participated in the victim survey were not only victims of stalking but also of other forms of domestic violence, such as sexual 23 abuse.

In the case of one woman, her partner recorded the sexual abuse and used the videos to threaten her: “Most of the abuse I experienced was of a sexual nature, and this abuse was often filmed on his phone; he would threaten that he would send these videos to my family.” Another victim was threatened with sexual violence via text messages: “Much of the texts were threatening, [e]specially regarding sexual things, which was particularly painful and shameful.”

Surveyed workers noted that some perpetrators take images or videos of their victim and use these as a means of intimidation. One worker wrote that perpetrators were “taking illicit photos and using them against women at difficult times in their relationships/or at the end of relationships.”

Another worker listed some examples she had observed in her practice: “Video cameras have been hidden in a bathroom or bedroom. Videos taken when unaware and put on YouTube. Recording sexual activities and then threatening to post or actually posting them online.” The research shows that perpetrators are using Facebook to humiliate women publicly, posting sexual images and videos where the women’s friends, family, and children can view them.

One worker wrote, “Social media sites provide an avenue for men to denigrate women via the viewing and sending on of pornography, which his partner and her friends can see.”

Another commented, “A video of the victim doing a seductive dance was shown to her children by her ex and used to degrade her to them via Facebook.” One surveyed worker explained that a victim’s ex-partner was using Facebook to humiliate her in front of her children and their friends: Women are having their Facebook page hacked into and nasty things written about and to them. One particular woman had her ex-partner saturate her page 24 with information about how he gave her an STI—this information was read by her teenage son’s friends, among other people.

Perpetrators also use Facebook to publicly shame victims and punish them for any perceived wrongdoings. A surveyed worker wrote, “Many situations I have encountered have involved men monitoring women’s status updates on Facebook and using this information to inflict injury on women or in their mind ‘punish’ them for their transgressions.”

Social networking sites can allow perpetrators to intimidate victims publicly, where shared friends and the community may support him and participate in the abuse: Social networking sites are being used quite a bit. Sometimes it will be a “status update” blaming his problems on her, or calling her names and accusing her of embarrassing shameful behavior. It seems that the truly hurtful aspect of this is the “comments” of support to him from family and friends that leave the victim feeling like she is being ganged up on by an entire community.

This is incredibly intimidating. Social media provides a public platform, affording the perpetrator an audience where he can torment the woman in front of her community of friends, extended family, and children.

DISCUSSION AND CONCLUSION

The central aim of the SmartSafe study was to examine whether mobile technologies present additional opportunities for the perpetration of stalking and domestic violence 25 against women. The findings confirm that mobile technologies are used by perpetrators to stalk and harass women in the context of domestic violence. However, several limitations of this research must be noted. The sample sizes were small, particularly the sample of victims. The sample used for the research was nonrepresentative and non-random and the recruitment method may have resulted in selection bias.

In addition, a large majority of the victims identified as Anglo-Australian and, as such, this sample was not culturally representative. In consultations, domesticviolence refuge workers revealed that women from non-English speaking backgrounds are particularly vulnerable to technology-facilitated stalking.

However, this group did not participate in the research. Another limitation is that workers, while important sources of information, may not recall events accurately. This study was based on two small, localized samples of domestic-violence workers and victims. There is increasingly widespread use of mobile technologies, particularly in developing nations (International Telecommunication Union, 2012).This trend, coupled with evidence that one third of women across the globe experience domestic violence, indicates that the findings from the SmartSafe study are not unique (World Health Organization, 2013).

Mobile Technologies: 24 Hour Access Through text messages, phone calls, GPS tracking, and social media, perpetrators use mobile technologies to stalk women, creating a sense of omnipresence and eroding women’s feelings of safety after separation. Perpetrators know that women have their phones with them day and night, and they use this knowledge to harass and abuse the women from a distance—easily, instantaneously, and repetitively.

The sending of 26 constant text messages may seem a trivial act, but the effect on women’s lives of receiving such messages is significant. In this study, victim participants wrote of feeling that they could never be free of their ex-partner, that he could reach her at any time, anywhere.

Omnipresence as a controlling tactic is common in coercive control. Technology provides not only more opportunities to use this tactic but also a larger range of methods, some of which facilitate abuse.

Ringrose et al. (2012) argue that technology is not neutral and the evidence gathered in the SmartSafe study shows that certain features of technology aid abusive and controlling behavior. Examples include the ease with which a perpetrator can use the GPS feature on his smartphone to track his partner or ex-partner without her knowledge; or use Facebook to monitor her, her friends, and her family; or repeatedly send abusive text messages, which are difficult to block.

Perpetrators Use Technology to Isolate Women from Their Support Systems Technology-facilitated stalking has wide-ranging implications for victims; women often have to change phone numbers, close Facebook accounts, and relocate to another state or country.

Changing a phone number or closing a Facebook account may seem minor inconveniences, but when situated in a pattern of coercive control, they are further consequences of the tactics perpetrators employ to isolate and intimidate women. Isolation from family and friends and a lack of social supports after a traumatic experience are linked with higher levels of psychological distress (Logan & Walker, 2009, p. 259). Isolation also contributes to depression and suicidal behavior in victims (World Health Organization, 2013).

When planning safety strategies for women, it is important to be mindful of the possible consequences of social isolation and to work with 27 women to ensure that their safety needs are balanced carefully with the potential for further isolation.

Perpetrators Use Mobile Technologies to Punish and Humiliate Women, Often in Sexualized Ways Intimate partner stalkers often use their knowledge of the women to shame and humiliate them. With mobile technologies, perpetrators can broadcast embarrassing and demeaning content to friends, family, and the community—easily and publicly.

By threatening to release the material, intimate partner stalkers control and intimidate women, an extremely fear-inducing situation for their victims. Social-media platforms, such as Facebook, provide perpetrators with public platforms to threaten and abuse their victims, sometimes with family members and friends participating in the harassment. The sexualized nature of technology-facilitated stalking can be considered a form of sexting.

Sexting is usually placed in the context of the “sexualization of culture,” described as the saturation of sexual imagery and messages in society, particularly those sourced from pornography (Ringrose et al., 2012). Concerns about sexualization center on the effects on young people. Although sexting is largely understood to occur among young people, the average age of the women who participated in the SmartSafe study was 35.

The findings of this study suggest that non-consensual sexting should be considered as a form of coercive control and be placed in the larger context of men’s violence against women. Mobile technologies can be useful for women experiencing violence, connecting them with assistance and enabling contact with their support networks.

However, this research shows that these technologies also provide more opportunities for perpetrators to 28 control, stalk, and abuse women in the context of domestic violence.

If women are to use mobile technologies safely, technology-facilitated stalking needs to be treated as a serious offence, and effective practice, policy and legal responses must be developed to address the use of technology as a tactic for abuse. The DVRCV are continuing advocacy in the area of technology-facilitated abuse through the training of domestic-violence workers and legal professionals, lobbying the communication industry, contributing to legal reforms, and developing technology safety resources for victims.

Published by Delanie Woodlock, Domestic Violence Resource Centre Victoria Woodlock, D (2015)Furtherreferences and notations regarding this paper can be found on their website.

A recent study linked obesity in children to domestic violence. Now, evidence indicates that childhood trauma can spur physical disease later on, when an abused child reaches adulthood. In Alaska, thestate is working to reduce adverse childhood experiences to lessen the latent impacts of trauma, and to help reduce the burden on social services programs.

In late Februray of this year, the conference room at a downtown Anchorage convention hall buzzed with chatter, in anticipation of keynote speaker, Linda Chamberlain. And Chamberlain has a strong message.

“Our early emotional experiences do become part of the architecture, the foundation of our brains. Our brains are incredibly plastic, during childhood, but don’t forget as I talk about this.. until the day you die, your brain is plastic,” she told the audience.

The event was a symposium hosted by the state Advisory Board on Alcoholism and Drug Abuse. Dr. Chamberlain told the audience that adverse childhood experiences, such as witnessing drug use and domestic violence, can stunt a child’s neurological development.

“The younger the child, the more vulnerable the brain is. The thing is, that you will go into a shelter, a domestic violence shelter, and I will see babies with PTSD. I know it right away. They’re avoiding eye contact, they are frozen, inhibited.”

The good news, she says, is that, with effort, negative brain wiring can be changed. Chamberlain bases her comments on the Adverse Childhood Experiences Study, or ACEs, which was conducted through the Centers For Disease Control and Kaiser Permanente during the late 1990s. Researchers found strong links between childhood traumas and long – term health and economic outcomes. Patrick Scidmore is a planner with the Alaska Mental Health Board.

“This is true of people who have ever been diagnosed with depression, people who have asthma, obesity. The negative outcomes are just more likely in the group with high ACES scores.”

Scidmore, is and a member of the state Advisory Board on Alcohol and Drug Abuse. His expertise is reading the data, and translating that to more tangible information.

“For example, for current smoking, we estimate from our Alaska data, 32 percent of the people who are current smokers would not be smokers if we could eliminate all adverse childhood experiences. And that translates into about $185 million dollars of savings to the state. Not necessarily state government, but across the public and private sector.”]

Scidmore says data gathered by the Alaska Division of Public Health during 2013 shows how childhood trauma contributes to chronic disease: for example, thirty percent of asthma sufferers in the state have links to ACES, and almost half of COPD patients have high ACES scores.

Since it is more cost effective in human terms to prevent childhood trauma, than to pay for the damage later on, social service providers are seeking ways in which to do that. Communities in several locations in Alaska are working on becoming “Trauma Informed”. Elizabeth Ripley is CEO of the Matanuska Susitna Health Foundation.

“Since the ACEs study was released, the brain science has caught up to the science behind the ACEs study, to show that literally, trauma changes the very physiology of the brain. But the good news that Linda Chamberlain shares is that we can heal the brain, but we have to be intentional about it.”

Ripley says Mat Su has eight personnel trained in how to inform the public – in schools,law enforcement, and in businesses — on efforts to reframe how we deal with childhood trauma. Especially in school, where children who act out are often misunderstood.

“We’ve tended to ask ‘what ‘s wrong with you?’ And this changes the framework to ‘what happened to you?”

Ripley says a cohort of Alaskans have worked with the original authors of the ACEs study to train 25 people from around the state to help by providing information about the prevalence and impacts of child trauma

“The information about the fact that people can heal, and that we can build resilience and help people heal from the trauma and have brighter futures, is really incredibly revelatory to most people.”

She says creating resilience is the key, and that just informing the public and private sectors that touch children is a huge part of the effort. Mat Su joins Homer, and a half dozen Alaska communities now working to become “trauma informed.”

No home is perfect, but dysfunction in the home is now revealed to be especially dangerous for children at risk for asthma. A new study shows that children exposed to just one adverse childhood experience (ACE) had a 28 percent increased chance of developing asthma than those with no ACEs.

The study, published in the Annals of Allergy, Asthma and Immunology, the scientific publication of the American College of Allergy, Asthma and Immunology (ACAAI), used data from the National Survey of Children’s Health. The survey drew from interviews with parents of more than 92,000 children aged 0 to 17 years to explore the relationship between ACEs, such as witnessing domestic violence, and the development of asthma.

“Of all the children in the sample, 31 percent were exposed to at least one ACE – the most common one being living with a parent or guardian who got divorced or separated,” said lead study author Robyn D. Wing, MD. “What surprised us was that among the children who had been exposed to 5 or more ACEs, 25 percent of parents or guardians reported that their child had an asthma diagnosis – compared with only 12 percent for those with zero ACE exposures. The data showed that the more adverse childhood experiences (ACEs) a child is exposed to, the greater the probability he or she will develop asthma.”

In addition to domestic violence, parents were asked if the child lived with anyone who had a problem with alcohol or drugs; if they lived with anyone who was mentally ill, severely depressed or suicidal; if they lived with anyone who served time in jail or prison; if a parent or guardian was divorced or separated; or if a parent or guardian had died. Of the study population, 68 percent had 0 ACEs, 17 percent had 1 ACE, 3.8 percent had 3 ACEs and 0.93 percent had 5 or more ACEs. The study also asked about smoke exposure and whether the parents felt safe in their neighborhood.

“We know that young children are susceptible to numerous adverse factors that they may be exposed to in the home environment – including cigarette smoking, indoor triggers, and even, as this study shows, dysfunctional families and associated domestic violence” said allergist James Sublett, MD, ACAAI president. “It is even more important that these high risk children are identified and cared for by experts in the management of asthma. Board Certified Allergist/Immunologists have special training in optimizing the care of children with asthma.”

Many people aren’t aware that allergists are experts in treating asthma, and can help both children and adults manage symptoms. For more information about treatment of asthma, and to locate an allergist in your area, visit AllergyAndAsthmaRelief.org.

About ACAAI The ACAAI is a professional medical organization of more than 6,000 allergists-immunologists and allied health professionals, headquartered in Arlington Heights, Ill. The College fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy and research. ACAAI allergists are board-certified physicians trained to diagnose allergies and asthma, administer immunotherapy, and provide patients with the best treatment outcomes. For more information and to find relief, visit AllergyandAsthmaRelief.org.

I have seen this so many times when a child with Trauma is diagnosed with ADHD and medicated when they have PTSD. Better understanding of childrens reaction to Trauma, and types of treatment available needs to be researched and implemented.

The fact that one in every 11 school-age children in the United States is diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) has warranted plenty of attention. Much research has focused on the efficacy of behavioral therapy or medication as well as a list of symptoms — hyperactivity, impulsiveness and inattention — used to identify ADHD.

According to the New York Times, the United States has one of the highest ADHD rates in the world, and nearly two-thirds of diagnosed children are treated with medication. This increase may indicate that borderline cases are now identified and treated, bringing help to patients in need. However, doctors concerned with the spike in attention deficit disorder rates argue that the clinical criteria for diagnosis have blurred the line between normal and abnormal behavior — and question whether the well-known symptoms of ADHD can mask deeper issues in children.

Are some childhood ADHD symptoms actually a response to trauma?

The Atlantic reports that while completing her residency at Johns Hopkins Hospital, Dr. Nicole Brown observed that a high number of her low-income pediatric patients had ADHD diagnoses. However, “Despite our best efforts in referring them to behavioral therapy and starting them on stimulants, it was hard to get the symptoms under control.”

Dr. Brown’s questions about the phenomenon led her to believe that rather than suffering from clinical neurological issues, some children were manifesting symptoms of another issue: post-traumatic stress disorder (PTSD). She hypothesized that trauma-induced hypervigilance and dissociation were easy to mistake for inattention, a common attention-deficit symptom. Likewise, children with overburdened stress responses were likely to behave impulsively.

Four or more ‘adverse childhood events’ made children three times as likely to be on ADHD medication

Her research results, pulled from a survey on the health and well-being of 65,000 children in the United States, indicated that children with an ADHD diagnosis also experienced high levels of poverty, divorce, violence and substance abuse among family members. According to the survey, a history of four or more “adverse childhood events” meant a child was three times more likely to be taking ADHD medication.

In response to the data from Dr. Brown’s study, the American Academy of Pediatrics is attempting to help clinicians identify and assess trauma in potential ADHD patients by revising their diagnostic guidelines. Such diagnoses should be made thoughtfully, particularly because the standard medication treatment for ADHD tends to be stimulant medication. This treatment could potentially further trigger anxiety and fight-or-flight reactions in PTSD patients, making symptoms worse, not better.

Differentiating between symptoms of ADHD and PTSD is complicated

Although Dr. Brown’s research showed a significant correlation between childhood trauma and the rate of medication treatment for attention deficit disorder, it’s important to note that establishing the correlative or causative relationship between trauma, symptoms, and disease is extraordinarily difficult. Still, the potential connection remains clear.

Unfortunately, the realities of the medical system make differentiating between symptoms of ADHD and childhood trauma difficult. With short appointment times and a heavy reliance on the parental disclosure of trauma, medical professionals may be unable to easily and quickly discern disease from dis-ease.

Does having an attention deficit disorder put children at greater risk for trauma?

While Brown’s work seeks to discern attention deficit from PTSD, other researchers note the increased likelihood of trauma in the life and background of an ADHD patient. Many physicians acknowledge that there is little direct causal connection between post-traumatic stress disorder and clinical attention deficit disorders, but Dr. Ellen Littman’s research attempts to clarify their interrelationship, noting a high possibility that the characteristics of the disease make trauma both more likely and more impactful in those with ADHD. This certainly complicates the issue of diagnosis.

Ultimately, diagnosis is a complicated assessment process, no step of which should be taken lightly. As the AAP releases new guidelines, clinicians will become more likely to identify what have come to be known as the classical symptoms of ADHD as potential symptoms of a variety of independent — or potentially interplaying — clinical issues. With clear adversity and trauma assessments, physicians can then establish a diagnosis which can ensure that children receive appropriate treatment with the least amount of side effects.

Monica Fuglei is a graduate of the University of Nebraska in Omaha

I have seen this so many times when a child with Trauma is diagnosed with ADHD and medicated when they have PTSD. Better understanding of childrens reaction to Trauma, and types of treatment available needs to be researched and implemented.